Rice University Proposed Effective Date: 07-01-2014 Aetna Whole HealthSM - Memorial Hermann- Aetna Select® - ASC
PLAN FEATURES
Deductible (per calendar year)
Member Coinsurance
Payment Limit (per calendar year)
Certain member cost sharing elements may not apply toward the Payment Limit.
Lifetime Maximum
Primary Care Physician Selection Referral Requirement
PREVENTIVE CARE
Routine Adult Physical Exams/ Immunizations
Routine Well Child Exams/Immunizations
Routine Gynecological Care Exams Includes routine tests and related lab fees Routine Mammograms
Women's Health
Routine Digital Rectal Exam / Prostate-specific Antigen Test
Colorectal Cancer Screening For all members age 50 and over.
Routine Eye Exams
Routine Hearing Screenings PHYSICIAN SERVICES Office Visits to PCP
Specialist Office Visits Pre-Natal Maternity Allergy Testing
Allergy Injections
DIAGNOSTIC PROCEDURES Diagnostic X-ray
Diagnostic Laboratory
Diagnostic X-ray for Complex Imaging Services EMERGENCY MEDICAL CARE
Urgent Care Provider
(benefit availability may vary by location) Non-Urgent Use of Urgent Care Provider Emergency Room
1 exam every 12 months for members age 22 and older.
7 exams in the first 12 months of life, 3 exams in the second 12 months of life, 3 exams in the third 12 months of life, 1 exam per year thereafter to age 22.
MAXIMUM SAVINGS Covered 100%
Covered 100%
MAXIMUM SAVINGS Covered 100%
Covered 100%
Includes: Screening for gestational diabetes, HPV (Human Papillomavirus) DNA testing, counseling for sexually transmitted infections, counseling and screening for Human Immunodeficiency Virus, screening and counseling for interpersonal and domestic violence, breastfeeding support, supplies, and counseling.
Covered 100%
$30 copay Covered 100%
One baseline mammogram for covered females age 35-39, one mammogram per calendar year for covered females age 40 and over.
$175 copay, waived if admitted Not Covered
$50 copay MAXIMUM SAVINGS
If performed as a part of a physician office visit and billed by the physician, expenses are covered subject to the applicable physician's office visit member cost sharing.
Covered 100%
If performed as a part of a physician office visit and billed by the physician, expenses are covered subject to the applicable physician's office visit member cost sharing.
$30 copay
Member cost sharing is based on the type of service performed and the place of service where it is rendered
Member cost sharing is based on the type of service performed and the place of service where it is rendered
Covered 100%
Includes services of an internist, general physician, family practitioner or pediatrician.
$30 copay
$20 copay MAXIMUM SAVINGS 1 routine exam per 12 months
Contraceptive methods, sterilization procedures, patient education and counseling. Limitations may apply.
Covered 100%
Covered 100%
Covered 100%
PLAN DESIGN & BENEFITS - CONCENTRIC MODEL
None Individual MAXIMUM SAVINGS
Only those out-of pocket expenses resulting from the application of coinsurance percentage and deductibles (except any penalty amounts) may be used to satisfy the Payment Limit.
Once Family Payment Limit is met, all family members will be considered as having met their Payment Limit for the remainder of the calendar year.
Unlimited None Family
$1,500 Individual Covered 100%
All covered expenses accumulate toward both the Payment Limits.
$3,000 Family Applies to all expenses unless otherwise stated.
Required Required
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Rice University Proposed Effective Date: 07-01-2014 Aetna Whole HealthSM - Memorial Hermann- Aetna Select® - ASC PLAN DESIGN & BENEFITS - CONCENTRIC MODEL
Non-Emergency care in an Emergency Room Ambulance Emergency Use
HOSPITAL CARE
Inpatient Hospital Coverage
Inpatient Maternity Coverage (includes delivery and postpartum care)
Outpatient Hospital Expenses (including surgery)
MENTAL HEALTH SERVICES Inpatient
Outpatient
ALCOHOL/DRUG ABUSE SERVICES Inpatient
Residential Treatment Facility Outpatient
OTHER SERVICES Convalescent Facility
Home Health Care
Hospice Care - Inpatient
Hospice Care - Outpatient
Private Duty Nursing - Outpatient (Limited to 70 eight hour shifts per calendar year)
Outpatient Short-Term Rehabilitation
Spinal Manipulation Therapy
Durable Medical Equipment Diabetic Supplies
Contraceptive drugs and devices not obtainable at a pharmacy
Transplants
Mouth, Jaws, and Teeth
(oral surgery procedures, when medical in nature) Out of Area Dependents
FAMILY PLANNING Infertility Treatment
Vasectomy
Tubal Ligation PHARMACY
MAXIMUM SAVINGS
Member cost sharing is based on the type of service performed and the place of service where it is rendered.
The member cost sharing applies to all covered benefits incurred during a member's inpatient stay
$250 per confinement copay
Pharmacy coverage is provided by EnvisionRX Options (http://www.envisionrx.com). See pages below for details.
Includes Speech, Physical, Occupational.
Covered 100%
Covered 100%
$250 per confinement copay MAXIMUM SAVINGS
$30 copay
$250 per confinement copay
$30 for Physician Services; $250 per confinement copay for Facility services
The member cost sharing applies to all covered benefits incurred during a member's inpatient stay
MAXIMUM SAVINGS
The member cost sharing applies to all covered benefits incurring during a member's inpatient stay
Member cost sharing is based on the type of service performed and the place of service where it is rendered.
Member cost sharing is based on the type of service performed and the place of service where it is rendered
MAXIMUM SAVINGS Limited to 20 visits per calendar year
Covered same as any other medical expense.
Covered 100%
Diagnosis and treatment of the underlying medical condition.
Covered 100%
$30 copay
No coverage for non-emergency care received outside the service area.
Covered 100%
MAXIMUM SAVINGS
The member cost sharing applies to all covered benefits incurred during a member's outpatient visit The member cost sharing applies to all covered benefits incurred during a member's inpatient stay
$30 copay
$30 copay
Preferred coverage is provided at an Institute Of Excellence contracted facility only.
Each period of private duty nursing of up to 8 hours will be deemed to be one private duty nursing shift.
Each visiting nurse care or private duty nursing care shift of 4 hours or less counts as one home health visit. Each such shift of over 4 hours and up to
Covered 100%
The member cost sharing applies to all covered benefits incurred during a member's outpatient visit
Covered 100%
Each visit by a nurse or therapist is one visit. Each visit up to 4 hours by a home health care aide is one visit.
$100 copay
$250 per confinement copay Not Covered Covered 100%
The member cost sharing applies to all covered benefits incurred during a member's inpatient stay
$250 per confinement copay
$250 per confinement copay
The member cost sharing applies to all covered benefits incurred during a member's outpatient visit, however specialist services performed in a hospital or other facility may be billed separately and covered as Physician Services for Non-Office Care.
The member cost sharing applies to all covered benefits incurred during a member's inpatient stay
The member cost sharing applies to all covered benefits incurred during a member's inpatient stay, however specialist services performed in a hospital or other facility may be billed separately and covered as Physician Services for Non-Office Care.
MAXIMUM SAVINGS
Prepared: 3/05/2014 Page 2
Rice University Proposed Effective Date: 07-01-2014 Aetna Whole HealthSM - Memorial Hermann- Aetna Select® - ASC PLAN DESIGN & BENEFITS - CONCENTRIC MODEL
Dependents Eligibility
Pre-existing Conditions Exclusion
Spouse, children from birth to age 26, regardless of student status.
They may also be subject to precertification or step-therapy. Non-prescription drugs and drugs in the Limitations and Exclusions section of the plan documents (received after open enrollment) are not covered, and medical exceptions are not available for them. While this information is believed to be accurate as of the print date, it is subject to change.
Plans are administered by Aetna Life Insurance Company.
This plan does not cover all health care expenses and includes exclusions and limitations. Members should refer to their plan documents to determine which health care services are covered and to what extent. The following is a partial list of services and supplies that are generally not covered. However, your plan documents may contain exceptions to this list based on state mandates or the plan design or rider(s) purchased by your employer.
Some benefits are subject to limitations or visit maximums. Certain services require precertification, or prior approval of coverage. Failure to precertify for these services may lead to substantially reduced benefits or denial of coverage. Some of the benefits requiring precertification may include, but are not limited to, inpatient hospital, inpatient mental health, inpatient skilled nursing, outpatient surgery, substance abuse (detoxification, inpatient and outpatient rehabilitation). When the Member’s preferred provider is coordinating care, the preferred provider will obtain the precertification. When the member utilizes a non-preferred provider, Member must obtain the precertification. Precertification requirements may vary. Depending on the plan selected, new prescription drugs not yet reviewed by our medication review committee are either available under plans with an open formulary or excluded from coverage unless a medical exception is obtained under plans that use a closed formulary.
On effective date: Waived After effective date: Waived GENERAL PROVISIONS
All medical or hospital services not specifically covered in, or which are limited or excluded in the plan documents; Charges related to any eye surgery mainly to correct refractive errors; Cosmetic surgery, including breast reduction; Custodial care; Dental care and X-rays; Donor egg retrieval;
Experimental and investigational procedures; Hearing aids; Immunizations for travel or work; Infertility services, including, but not limited to, artificial insemination and advanced reproductive technologies such as IVF, ZIFT, GIFT, ICSI and other related services, unless specifically listed as covered in your plan documents;
This material is for informational purposes only and is neither an offer of coverage nor medical advice. It contains only a partial, general description of plan benefits or programs and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee results or outcomes. Consult the plan documents (i.e. Group Insurance Certificate and/or Group Policy) to determine governing contractual provisions, including procedures, exclusions and limitation relating to the plan. With the exception of Aetna Rx Home Delivery, all preferred providers and vendors are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Aetna Rx Home Delivery, LLC, is a subsidiary of Aetna Inc. The availability of any particular provider cannot be guaranteed, and provider network composition is subject to change without notice.
Prepared: 3/05/2014 Page 3
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Toll-Free: 1-800-361-4542 Fax: 330-405-8081
Your prescription drug benefit is administered by EnvisionRxOptions. Headquartered in Twinsburg, Ohio,
EnvisionRxOptions has been providing pharmacy benefit management services nationally since 2001. Additional
information about EnvisionRxOptions and your prescription benefit can be found by registering at www.envisionrx.com.
The following information is an overview of the Rice University prescription drug benefit being administered by
EnvisionRxOptions.
Your prescription drug benefit features a formulary drug list. A formulary is a list of preferred medications organized into
groups or “Tiers”. Enclosed is a pocket formulary which lists the most frequently prescribed medications. For a full
formulary listing please visit www.envisionrx.com.
Copays, the portion of the drug cost that you are responsible to pay, are listed in the table below.
30-Day Retail 90-Day Mail Order
Tier 1 Generic
Tier 2 Formulary
Brand
Tier 3 Non-Formulary
Brand
Tier 4 Specialty Medications
Tier 1 Generic
Tier 2 Formulary
Brand
Tier 3 Non-Formulary
Brand Copay $10.00 $35.00 $55.00 25% up to $125.00 $20.00 $70.00 $110.00
Your benefit plan may have certain restrictions regarding refills. Please refer to the Summary Benefit Plan provided by
your plan or contact your Plan Administrator. You may also call our Customer Service Help Desk at 1-800-361-4542.
To access our Pharmacy Locator, please visit www.envisionrx.com. You may also call the EnvisionRxOptions Help Desk
at 1-800-361-4542 to see if your pharmacy is in the network.
Orchard Pharmaceutical Services
As a valued client of EnvisionRxOptions, we are pleased to provide mail order services through our affiliate company,
Orchard Pharmaceutical Services, located in North Canton, Ohio.
Mail order is an excellent way to receive prescriptions you will be taking for a long time with no worries about weather or
availability of supply at the local pharmacy. For individuals who are taking maintenance medications, you may want to
consider utilizing the mail order service for the convenience of home or office delivery.
Please refer to the enclosed Orchard Pharmaceutical Services Brochure for instructions on how to use the Orchard Mail
Order Pharmacy. You will need to obtain NEW 90 Day supply prescriptions from your physician. Mail the original
prescription(s) written for a 90 day supply of your medication (plus refills, if applicable) with the enclosed brochure, along
with your first payment or payment information.
Before you mail in a new prescription, you must REGISTER your information with Orchard Mail Order Pharmacy. You
may use any of the following 3 easy registration options:
1. Online: (Recommended method) Visit www.orchardrx.com and select Not registered? Click here to register.
Your account will activate within 24 hours. By registering online, members can also track the progress of their
orders.
2. Phone: Call Orchard Pharmaceutical Services Customer Service at 1-866-909-5170 to speak with a
representative.
3. Mail: Complete the Registration and Prescription Order Form enclosed in this packet.
Once registered, your Physician can fax your prescription(s) to Orchard at 1-866-909-5171. Only faxes sent from a
physician’s office will be valid.
Costco Specialty Services
Costco Specialty Services is the exclusive provider for your specialty medications as part of your prescription drug plan.
What this means for you is that you and those covered under your benefit will receive the personalized care and expertise
of Costco Specialty Services’ dedicated pharmacists, which is essential to successful therapy. This is because Costco
Specialty Services goes beyond traditional retail pharmacy, helping you get the most from your specialty medication
therapy.
Because specialty medications can be more difficult to manage, Costco Specialty Services offers the following patient
support services at no charge:
Personalized support to help you achieve the best results from your prescribed therapy
Convenient delivery to your home or prescriber’s office
Easy access to a Care Team who can answer medication questions, provide educational materials about your
condition, help you manage any potential medication side effects, and provide confidential support—all with
one toll-free phone call
